Cardiac rehabilitation

Primary care clinicians often don't receive their patients' discharge summaries from cardiac rehabilitation, according to
a new study. More...

Deep venous thrombosis

Selective use of D-dimer based on pretest probability identified first suspected DVTs with less testing

More selective use of D-dimer testing allowed physicians to safely and efficiently diagnose first episodes of deep venous
thrombosis (DVT), a new study found. More...

CMS update

Medicare participation deadline extended for 2013

Due to the last-minute action by Congress on the Physician Fee Schedule, the Centers for Medicare and Medicaid Services is
extending Medicare's 2013 Annual Participation Enrollment Program. More...

From ACP Internist

The next issue of ACP Internist is online

The January issue of ACP Internist is online and coming to your mailbox. More...

Call for cases

Have you as a physician been a patient? If so, ACP Internist wants to hear from you. More...

From the College

Call for fall 2013 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the fall 2013 Board of Governors meeting is March 20, 2013. More...

Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift
certificate good toward any ACP product, program or service. More...

Editorial note: ACP InternistWeekly will not be published next week due to the Martin Luther King Jr. Day holiday

Researchers conducted a nested, case-control study of data from primary care records in the U.K. that identified 487,372 people
who received antihypertensive drugs from 1997 to 2008. Patients were tracked for a mean of 5.9 ± 3.4 years, generating
more than 3 million person-years of follow-up. During this time, 2,215 were diagnosed with acute kidney injury that prompted
hospital admission or dialysis (7 in 10,000 person-years).

Taking a double-therapy combination of diuretics or ACE inhibitors or ARBs with NSAIDs was not associated with an increased
rate of acute kidney injury. However, a triple-therapy combination of a diuretic with an ACE inhibitor or ARB and an NSAID
was associated with a higher rate of kidney injury (rate ratio [RR], 1.31; 95% CI, 1.12 to 1.53). The risk was particularly
elevated in the first 30 days of treatment (RR, 1.82; 95% CI, 1.35 to 2.46) and progressively decreased, becoming insignificant
after more than 90 days of use (RR, 1.01; 95% CI, 0.84 to 1.23; P<0.001 for interaction).

The authors wrote, "Given that NSAIDs are widely used (40-60% as lifetime prevalence in the general population) and that a
greater incidence rate of acute kidney injury was estimated among antihypertensive drugs users than in the general population,
increased vigilance may be warranted when diuretics and angiotensin converting enzyme inhibitors or angiotensin receptor blockers
are used concurrently with NSAIDs. In particular, major attention should be paid early in the course of treatment, and a more
appropriate use and choice among the available anti-inflammatory or analgesic drugs could therefore be applied in clinical
practice."

An accompanying editorial noted that the study's confidence intervals were wide, that over-the-counter NSAID use could be unreported, that doctors who
monitored for this effect may have stopped treatment before kidney injury occurred, and that drug-associated acute kidney
injury is often a complication of other illnesses. Clinicians should talk to patients about risks and be vigilant for drug-associated
acute kidney injury, the editorial stated, because, "The jury is still out on whether double drug combinations are indeed
safe."

Three-pill generic-based antiretroviral therapy (ART) is cost-effective and could offer cost savings compared with a branded
single-pill regimen, a new study indicates.

Current U.S. guidelines for first-line treatment of HIV infection recommend a once-daily regimen of a branded pill containing
efavirenz, emtricitabine, and tenofovir. However, because a generic version of efavirenz is expected to be approved soon,
researchers performed a mathematical simulation to compare the clinical effect, costs and cost-effectiveness of standard therapy
and a once-daily three-pill regimen containing generic efavirenz, generic lamivudine and tenofovir. The latter regimen would
be less expensive but could decrease adherence and virologic suppression.

Three regimens were compared: no ART, three-pill generic-based ART (generic efavirenz and lamivudine plus branded tenofovir)
and one-pill branded ART (efavirenz, emtricitabine and tenofovir). The main outcome measures were quality-adjusted life expectancy,
costs, and incremental cost-effectiveness ratios (ICERs) in dollars per quality-adjusted life-year (QALY). The hypothetical
cohort entered into the mathematical model was similar to patients newly diagnosed with HIV infection in the U.S. in 2009.
Eighty-four percent were assumed to be men, and mean CD4 cell count at presentation was assumed to be 0.317 × 109 cells/L. Study results were published in the Jan. 15 Annals of Internal Medicine.

Generic-based ART had an ICER of $21,000/QALY compared with no ART. Branded ART versus generic-based ART increased lifetime
costs by $42,500 and increased survival gains per person by 0.37/QALY, leading to an ICER of $114,800/QALY. The authors estimated
that if all eligible U.S. patients started or switched to generic-based ART, $920 million would be saved in the first year
of treatment. Branded ART consistently showed an ICER greater than $100,000/QALY.

The authors noted that the efficacy of and price reduction with generic drugs are unknown, and that their estimates were conservative.
They also noted that the tradeoff between cost savings and health benefits may be controversial and that higher willingness-to-pay
thresholds could make the higher cost of branded regimens more acceptable. However, they concluded that the generic-based
regimen offered substantial cost savings compared with the branded regimen, although it was slightly less effective clinically.
"Starting or switching to generic-based regimens would initially yield annual savings approaching $1 billion for programs
that fund HIV treatment in the United States," the authors wrote.

The author of an accompanying editorial pointed out that recent changes related to the Affordable Care Act may make generic antiretroviral drugs more attractive to
some stakeholders. "HIV advocates and caregivers might more readily embrace generic antiretrovirals if…the savings
were diverted to address other funding needs within the field of HIV medicine," he wrote. Regardless, he concluded, "The era
of generic antiretrovirals in the United States has come."

Test yourself

MKSAP Quiz: a 6-month history of low back pain

A 20-year-old man is evaluated for a 6-month history of low back pain accompanied by prolonged morning stiffness. His symptoms
improve over the course of the day, but he is now unable to play recreational soccer. Rest, physical therapy, and acupuncture
have not improved his symptoms. Use of ibuprofen or diclofenac provides only partial relief. He has no other pertinent medical
history and takes no additional medications.

On physical examination, vital signs are normal. There is loss of normal lumbar lordosis, and flexion of the lumbar spine
is decreased. The low back and pelvis are tender to palpation. Pain increases when the patient crosses his legs. Reflexes
and muscle strength are intact.

Radiographs of the lumbar spine and sacroiliac joints are normal.

Which of the following studies is most likely to establish the diagnosis in this patient?

A: Bone scanB: CT of the sacroiliac jointsC: MRI of the lumbar spineD: MRI of the sacroiliac joints

Click here or scroll to the bottom of the page for the answer and critique.

Women's health

IUD for menorrhagia improved quality of life more than medical therapy

A levonorgestrel intrauterine device (IUD) improved quality of life more for women with menorrhagia than usual medical treatments
did, a recent study found.

The trial assigned 571 British women who presented to primary care with menorrhagia to treatment with the levonorgestrel IUD
or one or more medical therapies (including tranexamic acid, mefenamic acid, combined estrogen-progestogen or progesterone
alone). The primary outcome was the patients' change in score on the Menorrhagia Multi-Attribute Scale (MMAS), which ranges
from 0 to 100 and includes domains of practical difficulties, social life, family life, work and daily routines, psychological
well-being and physical health. The study was published in the Jan. 10 New England Journal of Medicine.

After six months, women in the IUD group and the usual treatment group both showed significantly greater improvements in MMAS
scores (mean increase, 32.7 points and 21.4 points, respectively; P<0.001 for both comparisons). The patients were followed for two years, and the greater benefit seen in the IUD group
was maintained (mean between-group difference, 13.4 points; 95% CI, 9.9 to 16.9 points). The IUD group had bigger improvements
in all of the MMAS domains and seven of eight studied quality-of-life domains. A higher percentage also kept the device for
two years compared with the percentage of those in the usual treatment group who continued treatment for two years (64% vs.
38%), although researchers noted this could have related to the need for a medical visit to discontinue use of an IUD. The
groups did not differ significantly in surgical intervention rates, sexual activity scores or serious adverse events.

Study authors concluded that the IUD was more effective than usual medical treatment in reducing the impact of heavy menstrual
bleeding on patients' quality of life. Most previous trials have been smaller and used the reduction of menstrual blood lost
as an outcome. The outcomes used in this study—the MMAS, quality-of-life measures, and sexual activity scores—may
be more relevant to patients. The authors did note that a subgroup analysis showed that the IUD was relatively less beneficial
in women with a body mass index below 25 kg/m2 than in heavier ones, perhaps because medical treatments have greater efficacy for them.

An accompanying editorial pointed out that the medical treatments most commonly used in the study (tranexamic acid, mefenamic acid or both) are rarely
used in the U.S. Still, the study adds to evidence that the IUD is superior to medical treatments for menorrhagia. The success
of the study's primary care approach also suggests that women could benefit from more involvement of generalist physicians
in treatment of this condition. More training in IUD insertion and FDA approval of the levonorgestrel IUD for heavy bleeding
(rather than just contraception) may be appropriate, the editorial concluded.

Cardiac rehabilitation

Primary care clinicians often don't receive their patients' discharge summaries from cardiac rehabilitation, according to
a new study.

Researchers performed an observational, cross-sectional study to determine how often and when primary care clinicians received
cardiac rehab discharge summaries, as well as their perception of and satisfaction with them. Between September 2008 and March
2011, consecutive enrollees at eight cardiac rehab programs in Toronto, Canada, were asked to give their consent to participate
in the study and to provide the names of their primary care clinicians. Clinicians were mailed an information letter and a
consent form and were in turn asked to participate. The researchers tracked the progress of discharge summaries to the clinicians'
offices, and those who received discharge summaries were sent a survey asking them to rate their satisfaction on a five-point
Likert scale. The study results were published online Jan. 8 by Circulation: Cardiovascular Quality and Outcomes.

Of the 577 clinicians invited to participate, 138 (24.0%) accepted. A total of 71 clinicians (51.5%) received cardiac rehab
discharge summaries, and of these 64 (90.1%) completed the survey. All of the clinicians in the study said they wanted to
receive discharge summaries, preferably (61.3%) by fax. Forty-seven (77.1%) reported they had used or planned to use information
from the discharge summary in patient care, but those who didn't receive the summary before a patient's first post-rehab visit
(n=7) were significantly less likely to ever use it (P<0.01). The researchers used a five-point Likert scale to assess the items considered most important to include in a discharge
summary and found that PCPs most valued information on medication (4.65±0.74), patient care plan (4.43±0.87),
and clinical status (4.33±0.94). However, 18.8%, 4.7%, and 22.2% of summaries, respectively, did not provide this
information.

The study authors acknowledged that the clinician response rate was low, that the generalizability of the results was not
known, and that the cardiac rehab sites were aware of the study objectives, among other limitations. However, they concluded
that a large percentage of primary care clinicians do not receive their patients' discharge summaries after cardiac rehab
and that this discrepancy reveals "a large gap in continuity of patient care." The results of their study suggest "that more
standardized strategies for [cardiac rehab] summary information gathering, generation, and transmission are required," they
wrote.

Deep venous thrombosis

Selective use of D-dimer based on pretest probability identified first suspected DVTs with less testing

More selective use of D-dimer testing allowed physicians to safely and efficiently diagnose first episodes of deep venous
thrombosis (DVT), a new study found.

The randomized, controlled trial included more than 1,500 patients who presented to Canadian hospitals with symptoms of DVT.
Physicians used the 9-point Wells clinical prediction rule to assess whether patients' clinical pretest probability of DVT
was low, moderate or high. Then patients were randomized to one group in which all patients were uniformly given D-dimer tests
(and given ultrasonography based on those results) or one in which pretest probability determined testing.

In the latter group, patients who had a low pretest probability and a D-dimer level below 1.0 µg/mL had DVT excluded
as their diagnosis. For patients with a moderate pretest probability, the D-dimer cutoff was 0.5 µg/mL. Patients who
scored below either of these levels did not receive ultrasonography. Outpatients with high pretest probability and all inpatients
were not given D-dimer tests and instead all received ultrasonography. Patients were followed for three months, and results
were published in the Jan. 15 Annals of Internal Medicine.

Study authors concluded that the selective testing was as safe as and more efficient than uniform testing and resulted in
a similar number of patients being diagnosed with VTE during testing. They noted that none of the patients with D-dimer levels
between 0.5 and 1.0 µg/mL were diagnosed with VTE during the study and that a very small percentage of the high-risk
patients in the control group had DVT excluded by D-dimer testing (15% of outpatients with high pretest probability and 2%
of inpatients).

They cautioned that the results may not be generalizable to patients with a history of DVT or to other D-dimer tests but called
for research on using selective testing in patients who present with suspected recurrences. For first suspected episodes of
DVT, the results support basing testing choices on pretest probability, they concluded.

CMS update

Medicare participation deadline extended for 2013

Due to the last-minute action by Congress on the Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS)
is extending Medicare's 2013 Annual Participation Enrollment Program.

The participation enrollment period will now end Feb. 15, 2013, instead of Dec. 31, 2012. This allows extra decision making time for those who may still be considering their options. For
more information about declaring your Medicare participant/nonparticipant status, please visit the CMS website.

From ACP Internist

The next issue of ACP Internist is online

The January issue of ACP Internist is online and coming to your mailbox. Featured stories include the following:

Taking a drink: what patients should know. Alcohol is associated with so many benefits and harms that it's hard to know where to start talking to patients about using
it. One place might be alcohol misuse and abuse. Teach patients where they fall on the continuum of drinking behavior. Take our poll on the topic.

Finesse required to treat anxiety in the elderly. Elderly patients may have many concerns on their mind, including maintaining their independence and managing their finances.
But when does worry become anxiety? And how can internists not only manage chronic diseases but also ensure that patients are able to care for themselves?

A few tips can improve older patients' memory. Most complaints of memory problems aren't signs of serious cognitive impairment and thus can be alleviated with a few simple tips.

These stories and the latest Test Yourself question from the MKSAP Quiz on a 67-year-old man evaluated for a 3-year history of low back pain are now online.

Call for cases

Have you as a physician been a patient? If so, ACP Internist wants to hear from you.

Our new column, "Doctor as Patient," will look at physicians' thinking as applied to their own health and wellness, based
on real stories from readers. It will be written by Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP, coauthors of
the bestseller "Your Medical Mind: How to Decide What Is Right for You." Both are on the Harvard Medical School faculty and
serve as staff physicians at Boston's Beth Israel Deaconess Medical Center.

If your submission is chosen for print, you'll receive a $50 gift certificate good toward any ACP product, program or service. Contact us if you have a story to tell. We look forward to receiving your submissions!

From the College

Call for fall 2013 Board of Governors resolutions

The deadline for submitting new resolutions to be heard at the fall 2013 Board of Governors meeting is March 20, 2013.

Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue
or topic that concerns them. When drafting a resolution, don't forget to consider how well it fits within ACP's Mission and Goals. In addition, be sure to use the College's Strategic Plan to guide you when proposing a resolution topic. Members must submit resolutions to their Governor and/or chapter council.
A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested
within its resolved clause(s) as either a policy resolve ("Resolved that ACP policy…") or a directive, which requests action/study on an issue ("Resolved that the Board of Regents…"). If more than one action is proposed,
each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution
format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members are
encouraged to use the Electronic Resolutions System (ERS) to research the status of past resolutions before proposing a new
resolution. Visit your chapter website and link to the ERS under the "Advocacy" heading.

Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate
good toward any ACP product, program or service.

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming
edition.

MKSAP Answer and Critique

The correct answer is D: MRI of the sacroiliac joints. This item is available to MKSAP 16 subscribers as item 41 in the Rheumatology
section.

MKSAP 16 released Part A on July 31. More information is available online.

This patient most likely has ankylosing spondylitis, and MRI of the sacroiliac joints is most likely to establish a diagnosis.
Radiographic evidence of sacroiliitis is required for definitive diagnosis and is the most consistent finding associated with
this condition. Onset of ankylosing spondylitis usually occurs in the teenage years or 20s and manifests as persistent pain
and morning stiffness involving the low back that is alleviated with activity. This condition also may be associated with
tenderness of the pelvis.

Typically, the earliest radiographic changes in affected patients involve the sacroiliac joints, but these changes may not
be visible during the first few years from onset; therefore, this patient's normal radiographs of the sacroiliac joints do
not exclude sacroiliitis. MRI findings of the sacroiliac joints can include bone marrow edema, synovitis, and erosions. Bone
marrow edema is the earliest finding and can precede the development of erosions. MRI, especially with gadolinium enhancement,
is considered a sensitive method for detecting early erosive inflammatory changes in the sacroiliac joints and spine and can
assess sites of active disease and response to effective therapy.

Bone scan can demonstrate increased uptake of the sacroiliac joints in patients with ankylosing spondylitis but is less sensitive
and specific than MRI.

CT is the most sensitive modality available to demonstrate bone changes such as erosions; however, it cannot detect early
changes such as bone marrow edema that precede erosive change in patients with ankylosing spondylitis.

In the diagnosis of early ankylosing spondylitis, sacroiliac joint MRI is more sensitive than lumbar spine MRI. Although changes
to the lumbar spine can be detected on MRI, they are usually preceded by changes in the sacroiliac joints. Therefore, if imaging
of the lumbar spine is negative, subsequent imaging of the sacroiliac joints would still be necessary to exclude ankylosing
spondylitis.

Key Point

MRI is considered the most sensitive method for detecting early erosive inflammatory changes in the sacroiliac joints when
radiographs are normal.

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IM Essentials Now Available in Print or Online

Internal medicine physicians are specialists who apply scientific
knowledge and clinical expertise to the diagnosis, treatment, and
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